Provider Demographics
NPI:1568288777
Name:LACEY, TAJA YVETTE MARIE
Entity type:Individual
Prefix:
First Name:TAJA
Middle Name:YVETTE MARIE
Last Name:LACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2863 PARK VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7242
Mailing Address - Country:US
Mailing Address - Phone:909-492-4015
Mailing Address - Fax:
Practice Address - Street 1:1845 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3467
Practice Address - Country:US
Practice Address - Phone:909-891-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-03
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician